Social History: (education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status) M.G. is a senior in high school. She is dual-enrolled in college-credit courses. She states she has good grades. She participates in softball and track. She participates in the FCA club after school with friends. M.G. denies the use of tobacco, nicotine, alcohol, and recreational drugs. She reports she is sexually active with boyfriend of 3 years. She states she uses condoms during sexual intercourse. She reports she wears her seat belt when riding in a vehicle. ROS General Denies fever, chills, decreased energy level and night sweats Cardiovascular Denies PND, orthopnea, edema, and tachycardia Pediatric SOAP Note
Skin Denies delayed healing, rashes, bruising, bleeding, skin discolorations, and any changes in lesions or moles Respiratory Denies cough, wheezing, hemoptysis, dyspnea, PNA/URI hx, and TB exposure. Eyes Denies the use of corrective lenses, eye discharge, blurring, and visual changes of any kind Gastrointestinal Denies abdominal pain, nausea/vomiting, diarrhea, constipation and eating disorders Ears Denies ear pain, ear discharge, hearing loss, ringing in ears, and excessive wax or discharge. Genitourinary Denies urinary changes, urine color, urgency/frequency, and dysuria. Positive for vaginal discharge xfew months. Denies foul, odiferous discharge but reports when discharge is present, it is thin and greyish/white color. Denies the use of contraception. Denies having a PAP or vaginal exam. Menarche at age 12. Positive for sexual activity with condom use. Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds, nasal discharge, dental disease, sore throat and hoarseness. Musculoskeletal Denies back pain, joint swelling, stiffness or pain, and fracture hx Breast Denies changes in breast and nipples. Admits to performing monthly self-breast exams. Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesia, and black out spells Heme/Lymph/Endo Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increased thirst, increased hunger, and cold or heat intolerance Psychiatric Alert and oriented. Maintains eye contact. Speech is clear and of normal rate and cadence. Answers questions appropriately. Denies homicidal/suicidal/anxious/depressive thoughts. OBJECTIVE ( plot height/weight/head circumference along with noting percentiles ) Attach growth chart Weight 125lbs (61%) Temp 97.9 F (oral) ̊ BP: 112/69 Height 67in (88%) BMI (20.2) Pulse 81 Resp 14 General Appearance and Parent ‐C hild Interaction M.G. is a healthy appearing, well-developing Caucasian female presenting in no acute distress. She is alert and oriented and answers questions appropriately.
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- Summer '17
- Candidiasis, vaginal discharge, Vaginitis